International Programs & Services
163 William St., 16th Floor
New York, NY 10038
212 346 1368
INTERNATIONAL
INTERNATIONAL STUDENTS AND SCHOLARS OFFICE
CHECK-IN SHEET
____________________________________
LAST NAME
_____________________________
FIRST NAME
___________
MI
U__ __ __ __ __ __ __ __
PACE ID #
_______________________________________________________________________________________________________________
US ADDRESS (STREET, CITY, STATE, ZIP)
**REQUIRED**
PHONE NUMBER______________________________________
E-MAIL ADDRESS______________________________________
GENDER (MALE / FEMALE)_________________________________ DATE OF BIRTH_____________________________________
MARRIED (YES / NO)________________________________
COUNTRY OF BIRTH____________________________________
COUNTRY OF CITIZENSHIP ________________________COUNTRY OF LEGAL PERMANENT RESIDENCY_________________
PACE SCHOOL:  LUBIN  DYSON  SEIDENBERG  EDUCATION  LIENHARD  LAW (PLEASE CHECK  ONE)
 GRAD_____
 UNDERGRAD__________
COMBINED DEGREE ____________
PERMANENT ADDRESS IN HOME COUNTRY: **REQUIRED**
STREET ADDRESS______________________________________________________________________________________________
CITY__________________________________________________________PROVINCE / STATE_______________________________
COUNTRY______________________________________________________ POSTAL CODE__________________________________
IMMIGRATION INFORMATION:
NON-IMMIGRANT STATUS:
_____F-1 _____J-1 _____ OTHER, PLEASE SPECIFY ___________
NO STATUS_______
PASSPORT #______________________________________ PASSPORT EXPIRATION _______________________ (MM/DD/YYYY)
VISA EXPIRATION _____________________________________ (MM/DD/YYYY)
I-94 FORM #____________
DATE OF LAST ENTRY TO U.S.______________________ (MM/DD/YYYY)
EMERGENCY CONTACT INFORMATION: **REQUIRED**
IN CASE OF AN EMERGENCY, PLEASE PROVIDE A NAME AND CONTACT INFO OF A RELATIVE OR FRIEND IN US:
NAME__________________________________________________________TELEPHONE_________________________________
ADDRESS___________________________________________________________________________________________________
RELATIONSHIP TO THIS PERSON______________________________________________________________________________
In case of an emergency, please provide a name and contact info of a relative or friend in your home country:
NAME______________________________________________________TELEPHONE________________________________________
ADDRESS______________________________________________________________________________________________________
RELATIONSHIP TO THIS PERSON __________________________ DOES THIS PERSON SPEAK ENGLISH? YES / NO (CIRCLE)
STUDENT’S/SCHOLAR’S SIGNATURE ________________________________
International Students and Scholars Office
DATE____________________________________
01/14/2014